Guidance to States and School Systems on Addressing Mental Health and Substance Use Issues in Schools

2019·0.25 MB·English

by  McCance-Katz, Elinore, Lynch, Calder

Joint Informational Bulletin
DATE: July 1, 2019
FROM: Elinore McCance-Katz, M.D., Ph.D., Assistant
Secretary for Mental Health and Substance Use
Calder Lynch, Acting Deputy Administrator and Director
Center for Medicaid and CHIP Services
SUBJECT: GUIDANCE TO STATES AND SCHOOL SYSTEMS ON ADDRESSING
MENTAL HEALTH AND SUBSTANCE USE ISSUES IN SCHOOLS
Together, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the
Centers for Medicare & Medicaid Services (CMS) are issuing this Joint Informational Bulletin
(Bulletin) to provide the public, including states, schools, and school systems, with information
about addressing mental health and substance use issues in schools. Specifically, this guidance
includes examples of approaches for mental health and SUD1 related treatment services in
schools and describes some of the Medicaid state plan benefits and other Medicaid authorities
that states may use to cover mental health and SUD related treatment services. Additionally, the
guidance summarizes best practice models to facilitate implementation of quality, evidence-
based comprehensive mental health and SUD related services for students.
Background
There is an urgent need to identify children and adolescents who have or are at risk for mental
disorders, including SUDs, and connect these children and adolescents with other services they
need. Schools can fill a critical role in both identifying such children and adolescents and
connecting them with treatment and other services they need.2,3 An estimated ten percent of
children and adolescents in the United States have a serious emotional disturbance (SED),4 yet
approximately 80 percent of those children and adolescents with an SED do not receive needed
services.5,6,7 Approximately 80 percent of children and adolescents with mental health diagnoses
have unmet mental health needs.8
Substance use rates among adolescents remain concerning, with over 16 percent of adolescents
ages 12 to 17 reporting illicit drug use during 2017,9 and more than 31 percent of adolescents
endorsing use of tobacco or alcohol during the same timeframe.10 Further, during 2017, four
percent of 12 to 17 year olds met criteria for a substance use disorder,11 with 82.5 percent of
those adolescents not receiving needed care.12
PEP19-SCHOOL-GUIDE
Intervening early is critical, given that half of all lifetime cases of mental illness begin by age 14
and three-fourths by age 24.13 Research has shown that early identification and treatment
improves outcomes. For example, early interventions conducted by comprehensive school-based
mental health and substance treatment systems have been associated with enhanced academic
performance,14,15 decreased need for special education,16 fewer disciplinary encounters,17
increased engagement with school,18 and elevated rates of graduation.19
However, most communities and schools lack high quality, comprehensive treatment for children
and adolescents. Many areas of the nation entirely lack or have insufficient numbers of
psychiatrists, psychologists, social workers, and other professionals, especially those with
experience in treating children and adolescents, to meet the growing needs.20 Navigating
complex systems to seek care often presents challenges for families and caregivers, such as long
wait times, insufficient available services, and poor insurance coverage.
Based on the aforementioned access challenges, schools are particularly critical in identifying
and supporting students with mental health issues. Unfortunately, schools often lack the capacity
to both identify and adequately treat mental disorders including SUD needs of their students.
School principals report that student mental health needs are one of their biggest challenges.21
Despite these challenges, integrating evidence-based mental health and SUD services into
schools can provide many benefits, including increased access to care and decreased stigma
when seeking treatment. Schools also can use multidisciplinary approaches to help provide early
identification, intervention, and a full continuum of services. Schools often collaborate with
community providers as a strategy to expand needed services. Typically, schools access funds
for school-based mental health and SUD services through a number of statutory authorities.
These include Medicaid benefits available under state plan authority, including benefits required
under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit; Medicaid
demonstrations and waivers, such as Section 1115 demonstration projects and Section 1915(c)
home and community-based services (HCBS) waiver programs; Section 1915(i) HCBS available
under the state plan; and non-Medicaid authorities, such as the Individuals with Disabilities
Education Act (IDEA) and Title I of the Elementary and Secondary Education Act, as amended
by the Every Student Succeeds Act (ESSA). It is important to also note that the Americans with
Disabilities Act (ADA) compels states to provide certain services for people with disabilities
including mental disorders within integrated settings,22 and Medicaid’s EPSDT benefit mandates
that states provide and arrange for services necessary to meet children’s medical needs, including
mental health needs.23,24,25
Best Practice Models
There are a number of best practice models, which are potentially funded by non-Medicaid
funding sources that can assist with supporting students with mental health and SUD related
needs in schools. As detailed below, states also have several options within Medicaid to support
school-based services.
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Multi-tiered System of Supports
Mental health and substance-related services in schools may be organized into a multi-tiered
system of supports (MTSS) that ranges from offering services universally to all students to
providing more intensive services for select students based on medical necessity.26 MTSS is an
umbrella term for an approach designed to respond to the needs of all students within a system
that integrates, but is not limited to, tiered behavioral and academic supports, and is part of the
structure of a comprehensive school-based mental health system. MTSS is a whole school, data-
driven, prevention-based framework for improving learning outcomes for all students through a
layered continuum of evidence-based practices and systems.27 Universally offered Tier 1
services (i.e., services offered to all students within a school system) typically include
widespread screening, social-emotional based learning curricula, and prevention-based activities
that foster healthy functioning in a generative school climate. Tier 2 services allow for early
intervention and targeted support (e.g., for students exhibiting risk factors often associated with
potential issues but for whom the issues have not fully manifested), and may include more
directed student screening and interventions to reduce the likelihood of issues developing or
resolve early manifestations of difficulty. Tier 3 services are generally for students identified as
experiencing mental health or substance-related difficulties, and may include individual or
family/caregiver treatment or other individualized interventions to address the identified illness
or condition.

Positive Behavioral Interventions and Supports (PBIS),28 the Interconnected Systems
Framework,29 and the Response to Intervention,30 are examples of approaches using an MTSS
framework. These MTSS programs involve modeling and practicing social skills with students,
then prompting and supporting their application in different contexts. Training students on
prosocial behaviors and supporting their use has been associated with improved school climates,
an enhanced sense of safety, and the perception of greater trust and respect in student-teacher
relationships.31 Additional evidence-based approaches using the MTSS framework to improve
pro-social skills and emotional awareness that can be incorporated into curriculum are referred to
as Social Emotional Learning (SEL), and their implementation has been associated with
improved academic achievement, reduced behavioral problems, and a positive economic return
on investment.32 Evidence-based programs and practices are those that have been carefully
evaluated and are supported by empirical data demonstrating improved outcomes. There are
multiple evidence-based programs and practices from which schools can choose to respond to
the needs of their students. Many evidence-based programs and practices, such as trauma
responsive school programs, positive disciplinary practices and bullying prevention programs,
cut across the three tiers to meet the comprehensive needs of students.

Comprehensive School Mental Health Systems
Comprehensive school mental health systems (CSMHSs) are an effective and broad multi-tiered
approach to caring for students. CSMHSs are school-community collaborations that provide a
continuum of mental health services across all three tiers of care (i.e., promotion and prevention
for all students, early identification and interventions for those students at risk, and indicated
treatment for those students with more intensive needs). There are innovative opportunities for
these collaborations to enhance the mental health of students, improve the school climate, and
decrease student social isolation and marginalization.33,34 Key aspects of the CSMHS approach
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include evidence-based universal prevention efforts, training for school and community members
to identify and respond to early warning signs of mental health difficulties, and targeted
prevention and intervention programs and services supporting the mental health of students. The
CSMHS framework includes integrating mental health care delivery within school settings.

In addition to collaborations with community mental health providers and families, CSMHSs
with their host schools, can develop collaborations with the faith community, law enforcement,
physical health care providers, community mental health and substance treatment providers,
local businesses, and government agencies. These collaborations can be utilized to help prevent
mental health or substance use issues among children and adolescents in schools, better identify
and support children and adolescents with mental disorders including SUDs, and make referrals
to needed treatment for mental health and substance use issues. Although the school system
plays an integral role in ensuring the sound mental health of its students, a comprehensive
community approach has been essential to the successful expansion of school-based mental
health systems.

Schools and their community partners that have implemented CSMHSs often utilize the School
Health Assessment and Performance Evaluation system (SHAPE), a free, web-based portal that
provides a virtual workspace for self-assessment of their CSMHS’s level of quality
implementation based upon the National Indicators for School Mental Health.35 SHAPE also
provides schools and community partners with a “blue print” to inform ongoing planning and
implementation in building their CSMHS based best practices and quality indicators. The
SHAPE system can also help CSMHSs identify needed services, such as global screening,
wellness education, psychotherapy and counseling, access to medication when indicated, and
case management. The SHAPE system also addresses factors that can facilitate the expansion of
the mental health and substance treatment workforce within and outside of schools in order to
support the provision of school-based mental health and substance related services. The National
Center for School Mental Health (NCSMH) at the University of Maryland School of Medicine,36
a sub-recipient of a Health Resources and Services (HRSA) grant to support the Collaborative
Improvement and Innovation Network on School-Based Health Services (CoIIN-SBHS)
project,37 also supports the SHAPE system, which it offers at no cost to all schools and school
districts nationally that are interested in improving and strengthening their school mental health
and substance related services.

States have also received SAMHSA funding to implement Safe Schools/Healthy Students
(SS/HS) or Project Advancing Wellness and Resilience in Education (AWARE) grants. The
SS/HS framework provides schools and communities with a template for implementing best
practices to prevent violence among children and adolescents, and has been found to reduce
suspensions and expulsions by half, reduce risks associated with depression by 51 percent, and
decrease the number of students staying home from school due to feeling unsafe by 37
percent.38,39 SAMHSA has provided SS/HS funding to seven states, and profiles of the
initiatives in these states are available online.40 While SAMHSA no longer funds SS/HS grants,
SAMHSA’s Project AWARE grants support states in developing quality comprehensive school
mental health systems that seek to meet the needs of all students. The first Project AWARE
grants funded 20 States in 2014. A second Project AWARE cohort of 24 states and tribes began
in 2018, and a third cohort is planned for implementation in the spring of 2019 when
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approximately six additional states and two tribes are expected to receive Project AWARE grant
funds.41 Project AWARE has demonstrated improved ability to identify and refer children and
adolescents with mental health problems to appropriate treatment, with nearly a 10-fold increase
in referrals achieved from fiscal year 2015 to fiscal year 2016.42,43 Further, Project AWARE
participants who were non-clinician mental health helpers, received Youth Mental Health First
Aid training, after which they reported significantly improved mental health literacy, and
significantly enhanced confidence in being able to provide appropriate help to students when
indicated.44 Additionally, Project AWARE performance outcomes reported by grantees included
improved school climate, improved school safety, and improved student coping and resiliency
skills.45

It should be noted that the cost of implementing a comprehensive system varies due to the range
of student needs, evidence-based practices used, and reimbursement for services by public and
private insurance. Financing of CSMHSs may require multiple streams of funding. Federal
grants, such as SS/HS and Project AWARE, have assisted or are currently assisting over 50
states, territories, and tribal entities in the development of school mental health systems.

Building Mental Health Literacy
Building mental health literacy is a universal prevention strategy that schools can implement
with all staff and students within a specific school, school district, and/or more broadly within
the community. Raising awareness and literacy around mental health issues is a critical
component of improving school-based mental health. Mental Health First Aid and Youth Mental
Health First Aid are examples of mental health literacy training programs designed to provide a
basic understanding of common mental health issues and how to refer people in mental health
crises appropriately. These training programs are widely available to school personnel, parents/
families/caregivers, first responders, law enforcement, and others in communities, with more
than one million people across the nation already trained.

Research has indicated that gains in mental health knowledge over the course of the mental
health literacy trainings were associated with increased help-seeking intentions, suggesting that
mental health literacy may facilitate treatment utilization. Generally, as of 2018, instructor
training costs between $1,500 and $2,000, while individual course training varies, with an
average cost of $119. This training can empower school staff with skills to recognize and assist
students experiencing mental health needs and better prepare them to make appropriate referrals.
Various non-Medicaid funding sources for mental health literacy training may be explored, such
as those listed in the section below entitled, “Funding for School-Based Mental Health and
Substance Use Related Prevention and Treatment Services.”

Counseling, Psychological, and Social Services Coordinators
Establishing counseling, psychological, and social services (CPSS) coordinators can have a
positive impact on the quality and delivery of mental health and other related services.46 CPSS
coordinators can coordinate various providers within and outside of schools to meet students’
needs.47 Coordination of services can also result in a clear mission, goals, and objectives that
promote the integration of procedures and programs.48 Integration of services within the larger
school environment helps secure resources, such as provision of confidential space for providing
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services, and helps minimize lost class time for students seeking services. A recent survey of
school districts nationwide revealed that 79.5 percent had staff to oversee or coordinate CPSS.49

School Resource Officers
The National Association of School Resource Officers (NASRO) underscores three primary
roles of the school resources officer (SRO)—namely, that of educator and guest lecturer, that of
informal counselor or mentor, and that of law enforcement officer.50 The SRO is a non-
Medicaid covered mechanism utilized by many schools. When implemented with a highly
trained officer, SROs can be an invaluable component of creating a safe and supportive school
climate. SROs can be an integral member of multi-disciplinary teams within schools,
collaborating with teachers, administrators, mental health providers and guidance counselors in
the best interest of the students. SROs can directly help identify students with mental disorders
including SUDs to connect them with appropriate mental health or substance use services in the
school. By fostering positive relationships with students, SROs can also help address situations
that students bring to their attention for other children or adolescents who may need support.
Further, SROs can have an online presence to help identify potential student needs and
encourage indicated help seeking through school-based mental health and substance related
resources.51

Crisis Intervention Teams (CITs)
Law enforcement officers well trained in mental health issues can be a tremendous asset to the
local school systems. CITs are a community partnership of law enforcement, mental health and
substance use practitioners, individuals living with mental disorders including SUDs, their
families/caregivers and other advocates that provide specific training to law enforcement and
other first responders in safely responding to people with mental disorders or experiencing a
mental health emergency who are in crisis. While CITs are not limited to a school environment,
they can help address crises within school settings as they may in other parts of a community.
This innovative first responder model helps people with mental disorders including SUDs access
medical treatment rather than the criminal justice system and promotes officer safety and the
safety of the individual. The CIT model reduces both stigma and the need for further
involvement with the criminal justice system and provides a forum for effective problem solving.
Research also suggests that communities that subscribe to the CIT model have higher success
rates in resolving crises.52

Behavioral Health Aides and Peer Supporters
Support from behavioral health aides and peers can be critical to help children and adolescents
and their families and caregivers navigate challenges associated with mental and substance use
issues, and can enhance efforts of practitioners and others in the school and health system.
Trained peers can develop trust and effective relationships through similar lived experiences with
others facing mental and substance use difficulties,53 and have been found to improve quality of
life, engagement, and satisfaction with services and supports, improve overall health, and reduce
overall cost of services.54 While not specific to school-based settings, research has demonstrated
the clinical and social/emotional benefits for individuals with mental illness receiving peer
support, including reductions in hospitalizations, increased feelings of respect, humanity, and
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trust, and increased empowerment to engage in care and pursue personal goals.55,56 Peer
supporters are included in various settings across the nation including child-serving systems, and
include student peer counseling programs and statewide peer and family support
organizations.57,58 In 2015, 37 states used various funding sources to provide peer and consumer
run services.59

Workforce and Rural Setting Considerations
Some settings, including rural locations, have unique challenges regarding building an adequate
mental health and SUD treatment workforce. While important, these factors are beyond the
focus of this document, so will not be addressed in detail. However, Appendix A highlights
information addressing workforce shortages, training the mental health and SUD treatment
workforce, and using “telemental health” to expand access to mental health and substance related
services in rural schools or other settings in which particular difficulty may be experienced
recruiting or retaining qualified mental health and SUD treatment practitioners.

Funding for School-Based Mental Health and Substance Use Related Prevention and
Treatment Services

Various funding sources can be utilized to pay for the costs of school-based mental health
services, including to:60

1) leverage diverse funding streams and resources to support a full continuum of services;
2) increase reliance on more permanent funding;
3) apply best practices strategies to retain staff;
4) use economies of scale to maximize efficiencies;
5) utilize third party reimbursement mechanisms (i.e., Medicaid, Children’s Health
Insurance Program (CHIP), private insurance) for these services;
6) implement evidence-based practices and programs to maximize return on investment;
7) evaluate and document outcomes, including impact on academic and classroom
functioning, using outcome data to inform states, school districts, and community
partners; and
8) apply for public grants, formula grants (e.g., via ESSA, or the Office of Juvenile
Justice and Delinquency Prevention), block grants such as the Community Mental Health
Services Block Grant or discretionary/program grants (e.g., Garrett Lee Smith Suicide
Prevention, Project AWARE, SAMHSA Systems of Care, HRSA Workforce
Development), as a time-limited bridge to more sustainable funding streams.

Many states have used multiple financing strategies for school mental health and SUD related
prevention and treatment services, including the use of Medicaid. Medicaid is a state-federal
program in which states have the flexibility to design their programs and the services offered,
subject to federal requirements. Each state develops and operates its Medicaid program under
a state plan outlining the nature and scope of services. Subject to federal requirements, states
choose which eligibility groups and services to include (some eligibility groups and services
are mandatory, while others are optional), which providers may participate and the payment
methods that will be used to pay for services. The Medicaid state plan and any amendments
to the state plan must be approved by CMS. States may also pursue other Medicaid statutory
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authorities to support the populations and services they wish to cover, subject to CMS
approval. The FY 2016 CMS Medicaid Financial Management Report indicates that forty-
five states and the District of Columbia offer reimbursement for a range of school-based
services, which would include all Medicaid reimbursable school-based services. 61

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Some specific examples of state-level strategies for Medicaid and other financing of school-
based mental health services can be found in the table below.

STATE DESCRIPTION
Alabama Alabama Departments of Education and Mental Health developed cross system
funding to support school-based mental health programming.62
Arkansas Developed administrative procedures to finance a school-based mental health
program. Arkansas also formed a state-level collaboration between their
Departments of Education, Mental Health/Behavioral Health, and Juvenile Justice
for shared funding of school-based services,63 and a comprehensive manual of
Arkansas’s approach to school-based mental health within their State is available
online.64
California Passed the “Mental Health Services Act,” which levies a “1% income tax on
personal income in excess of $1 million”65 to support mental health initiatives,
including comprehensive school-based mental health systems.
Florida Utilized a SAMHSA Project AWARE66 grant to produce a “Universal Screening
Planning Packet,” designed to guide schools in implementation of broad-based
mental health screening so that students may receive further support and mental
health services when indicated.
Louisiana Used Medicaid state plan authority in LA 15-0019 to cover the services of a
licensed nurse in the school setting for Medicaid-eligible students with an
“individualized health plan” thereby not limiting the nursing services to services in
an Individualized Education Plan (IEP.)
Massachusetts Amended their Medicaid state plan to cover services within Individual Health Care
Plans, Individualized Family Service Plans, Section 504 plans, or services
otherwise deemed medically necessary. The state plan amendment MA 16-012 was
approved on July 17, 2017 and was effective on July 1, 2016.
Michigan IDEA revisions expanded counseling sessions for students at elevated risk for
mental health concerns (i.e., “Tier 2”) and for those with existing mental health
needs (i.e., “Tier 3”).
Nevada The governor’s state-funded block grant called “Social Workers in Schools” began
in the 2015-2016 school year, and provides full-time social workers to address
mental health/behavioral health issues identified on school climate surveys.
Through “Social Workers in Schools,” the Department of Education’s Office for a
Safe and Respectful Learning Environment has placed over 225 social workers in
170 schools over the past two years.67

South Department of Education created a “Psychosocial Behavioral Health Rehabilitative
Carolina Medicaid Standard” for students in Tiers 2 and 3 to enhance coverage for school-
based services.68 South Carolina also developed a recurring line item in the state
budget to ensure funding for rural communities to develop school mental health
programs.69
Tennessee Johnson City designated school mental health funding for case managers in schools
to provide Tier 2 and Tier 3 level services.70
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Medicaid Coverage of Mental Health and Substance Treatment Services

The following section describes general Medicaid requirements, state plan benefits that may
be used to cover services to treat mental disorders including SUDs, and other Medicaid
authorities that may be used to cover these services.

Section 1905(a) State Plan Services

The Medicaid state plan is a comprehensive written statement that describes the nature and
scope of a state’s Medicaid program and contains assurances that the program will be operated
per the requirements of Title XIX of the Social Security Act (Act) and other official guidance.
While there is no distinct Medicaid state plan benefit called “school health services” or “school-
based services,” states may submit a state plan amendment (SPA) to provide such services and
ensure that services are covered by Medicaid and eligible for federal financial participation
(FFP). The state’s Medicaid state plan must provide for coverage of mandatory services and
include any optional services that the state elects to cover and must include a comprehensive
description of the state’s method of payment for those services.

A coverage SPA must meet three basic tenets of comparability, freedom of choice of provider,
and statewideness, except in the limited circumstances where a particular benefit included in
that SPA allows for any of these requirements to be disregarded.

Comparability: A Medicaid-covered benefit generally must be provided in the same
amount, duration, and scope to all enrollees within a group;

Freedom of choice: Medicaid beneficiaries must be permitted to choose a health care
provider from any qualified provider who undertakes to provide the services, and any
willing and qualified provider must be able to participate in the Medicaid program;
Statewideness: The plan will be in operation statewide under equitable standards for
assistance and administration that are mandatory throughout the state.

In addition, a coverage SPA must meet the requirements for coverage under the particular
benefit, and include any limitations on amount, duration, and scope of services.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Benefit
The EPSDT benefit provides a comprehensive array of prevention, diagnostic, and treatment
services for Medicaid-enrolled children under age 21 as specified in section 1905(r) of the Act.
The EPSDT benefit requires states to have a schedule for screening services both at established
times and on an as-needed basis. Covered screenings for children include medical, mental
health, vision, hearing, and dental. Incorporating an age appropriate, evidence-based screening
tool designed to identify behavioral health conditions into well-child examinations is an
important step to identify mental health and SUD conditions early. In addition, the EPSDT
benefit requires that states provide all medically necessary services covered under the benefits in
section 1905(a) of the Act to correct or ameliorate physical and mental illnesses or conditions.
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